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Saturday, September 25, 2010

Laparoscopic Surgical Treatment of Pain From Chronic Prostatitis

Laparoscopic radical prostatectomy is a technical and demanding technique used to remove the prostate.Since the late 1990s, this surgical technique has been used for the treatment of prostate cancer. However, its possible uses may be expanding – in very carefully selected and unusual cases – to include the treatment of chronic prostatitis. Should every patient with pain rush to have his prostate removed?

Some forms of pain are good. For example, pain is good when it forces us to remove a hand from a fire. Other forms of pain are bad. Pain is bad when it chronically distracts us from our appointed rounds. For example, an amputee may have pain in a hand that no longer exists; this kind of pathological pain, which fulfills no apparent constructive purpose, can keep the amputee from concentrating on other things.

Pathological pain can also arise from the viscera: The abdominal contents. Common examples are Irritable Bowel Syndrome and Endometriosis, the pain of which is can be hard to localize and treat. For all intents and purposes, visceral pain is not treated surgically. Should the pain of prostatitis be treated surgically?

Prostatitis falls into two broad and general categories: Infectious and non-infectious. The infectious kind is generally associated with bacteria, causes fever and pain, and is easily treated with antibiotics. The non-infectious kind, which can last for years and even decades, is characterized by episodic pain, fatigue, inability to think clearly, depression, and social isolation. Its causes are not known and the treatments have remained elusive. One theory to explain severe, treatment-resistant, chronic prostatitis is that it is really a psycho-somatic manifestation of neurosis and distress. In other words, the theory holds that severe, treatment-resistant, chronic prostatitis is “all in your head” and should be treated with psychotherapy, massage, and trigger point release.

Beginning in 2007, evidence has been anecdotally accumulating that severe chronic prostatitis may be completely curable with laparoscopic radical prostatectomy. Specifically, a 55-year old man with an 8-year history who had exhausted all other options had this surgery and was instantly cured. Since then, a handful of other men have had such treatment as part of an ongoing, IRB-approved prostatitis treatment clinical trial that follows symptoms measured by the Chronic Prostatitis Symptom Index (CPSI) over time. They seem to be also improving, although the response is not completely uniform, the symptoms are receding at different rates, and a minority appears to be getting little, if any, therapeutic effect.

So why should a man in pain not try laparoscopic radical prostatectomy? The answer lies in the risk analysis. Laparoscopic radical prostatectomy is associated with infertility, which for men at child-bearing ages as is the case with prostatitis sufferers, is a major issue. It is also associated with risk of urinary incontinence, erectile dysfunction, bladder neck contracture, cardiovascular complications, infection, and treatment failure. Given that some prostatitis prostates are embedded in a dense reaction that causes adherence of the prostate to the rectum, there is risk of rectal injury.

Men with severe, treatment-resistant, chronic prostatitis have no good options. It may be that laparoscopic radical prostatectomy can help some of them to feel better. However, the promise of this approach is only in the earliest phases of validation and the risks associated with it are serious and real.

To learn more, readers are invited to follow the Prostatitis News Blog, which will post results of the trial as they come in, as well as information on many other facets of prostatitis.

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